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CNUR 305 > Advanced Neurological Concepts > Flashcards

Advanced Neurological Concepts Flashcards

1
Q

What is a spinal cord injury? what is the morbidity and mortality?

A

Any injury to the neck or back that interrupts spinal cord functioning. Cervical is most common injury.
Usually males age 15-25
Life span decreased by 15-30 years
Mortality effect most by respiratory complications (pneumonia), renal (UTI) and Integumentary (Pressure ulcer)

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2
Q

What are the three types of acute spinal cord injuries?

A

Destruction (direct trauma)
Compression (by bone fragments, hematoma, or disk material)
Ischemia (Damage or impingement on the spinal arteries

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3
Q

What are the three results of neurological damage in the moment of spinal impact?

A

Cord compression, direct cor injury, disruption of cord blood supply

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4
Q

What is a secondary spinal injury? What are the causes?

A

Injury which occurs after the initial injury.

May be caused by swelling/inflammation, ischemia, moving of bony fragments.

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5
Q

What is a tetraplegia injury?

A

No movement in all 4 limbs

Will require manual ventilation

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6
Q

What is a paraplegia injury?

A

No movement in lower 2 limbs, Below C8

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7
Q

How is Neurological injury classified?

A

By the lowest segment of the spinal cord, where motor and sensory function on both sides of the body are normal

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8
Q

What is the dermatomes assessment?

A

Sensory assessment
Test the sensory points on each side of the body, with the sharp and dull ends of a paperclip
Have the patient’s eyes closed

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9
Q

High-Cervical Nerves (C1-C3) Most Severe

What is the movement functioning? ADLs? Complications?

A

Tetraplegia, spastic paralysis
Require complete assistance for ADLs
Respiratory- require mechanical ventilation, apnea is fatal
No bowel or bladder control
Need a wheelchair with special mouth control

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10
Q

Spinal cord injury:C6

Function and ADLs

A

Weak grasp
Has shoulder/bicep control to transfer ad push w/c
No bowel/bladder control
Requires some assistance, still has some degree of independence

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11
Q

C5 keeps _________ alive

A

Diaphragm

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12
Q

Thoracic T1-6 Injury

What is the movement functioning? ADLs?

A

Full use of upper extremities
Can transfer themselves in position changes
Can still do ADL’s with some modifications
Can Drive a vehicle with hand controls
No bowel/bladder control

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13
Q

Classifications of SCI: Amount of Cord injury, what is a complete transection?

A

No transmission of messages beyond the level of the injury

No sensation and no voluntary movement below the level of injury

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14
Q

Classifications of SCI: Amount of Cord injury, what is a Incomplete Transection?

A

Some messages are being transmitted
Interrupted messages may be motor, sensory or a combo of both
Variable degree of loss of function and sensation

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15
Q

What is Neurogenic Shock? What are the signs and symptoms?

A

Involves the SNS and results in autonomic instability
Hemodynamic syndrome that can occur in 30 minutes after injury and last up to 6 weeks
SCI and or above T6
Loss of sympathetic input from hypothalamus- decreased SNS vasoconstrictor tone
Parasympathetic is unopposed and takes over
-Massive vasodilation without compensation- venous pooling and decreased cardiac output
No sympathetic response and no compensation
Symptoms:
1. Hypotension-Rx, fluids and inotropes
2. Bradycardia- Rd, atropine, pacemaker
3. Peripheral Vasodilation- warm, flushed

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16
Q

What is spinal shock?

A 
The loss of motor and sensory after trauma
Occurs in 50% of patients with SCI
Temporary in Acute phase
Will resolve with gradual recovery of reflexes
Symptoms below the injury:
Reflexes depressed/absent
Loss of sensation
Flaccid Paralysis
Everything below is flaccid
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17
Q

What is Autonomic Dysreflexia? What are the signs and symptoms?

A

T6 or higher
What: Loss of normal compensatory mechanisms when sympathetic nervous system is stimulated
Triggers are visceral stimulation
Over distended bladder, bowels
Pain
Sensory stimulation
Vasoconstriction of vessels below SCI, BP rises, baroreceptors sense BP and parasympathetic activated, PNS attempts to lower BP and heart rate

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18
Q

What are the divisions of the peripheral nervous system?

A

Autonomic: Sympathetic and Parasympathetic
Somatic: Allows the voluntary movement of muscles within the body, Receives sensory input

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19
Q

What is the normal sympathetic response?

A

Fight or Flight
Turned on in response to a significant stressor
Release of epinephrine and norepinephrine
Increased BP, increased heart rate, vasoconstriction, diaphoresis, dilated pupils, goosbumps

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20
Q

What is the normal Para-sympathetic response?

A

Resting and Digesting
Opposite response to Fight or Flight
Increase in Acetylcholine
Peristalsis, decreased BP, decreased heart rate, vasodilation,constricted pupils

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21
Q

How is the stress response altered in those with a SCI?

A

SNS activates, BP rises
Baroreceptor sense increased BP
Parasympathetic system is activated but can only create a response down to the level of injury
Above SCI: There will be parasympathetic activation- Vasodilation, Bradycardia
Below SCI: Continue to see sympathetic activation- severe constriction of blood vessels which will cause the BP to continue to climb until AD is rectified

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22
Q

When a patient is experiencing autonomic dysreflexia, which action should the nurse complete first?
Notify physician, assess foley cath patency, place patient in trendelenburg, place patient in high fowlers

A

Place patient in trendelenburg, assess foley cath

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23
Q

Autonomic Dysreflexia Nursing Interventions

A

1st: Raise HOB to 90 degrees, remove or loosen any abdominal binders, ted hose, foley leg straps
2nd: Rule out each cause, start with most common (full bladder, bowel, impaired skin integrity
3rd: Monitoring, BP control

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24
Q

What is the collaborative care for SCI?

A
  1. Sustain Life
  2. Prevent further injury

ER: Trauma protocol, primary survey (ABCDE), Secondary Survey, Foley, NG

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25
How can a C-spine be 'cleared'?
``` ONLY by a physician!! ONLY can be cleared clinically (without xray) if the patient: -is awake and orientated -has no distracting injuries -Has no drugs/ETOH in board -Has no neck pain -Is neurologically intact ``` Diagnostics: Xray initially MRI is the gold standard
26
What is the drug therapy for SCI?
High dose methylprednisone:(For inflammation) loading dose/infusion within 8 hours of injury Inotropes: MAP 80-90 SYmptomatic Treatment: eg. Bradycardia, GI, stress, ulcers, hypoactivity, short term pantoloc
27
Ongoing drug therapy for SCI?
``` Control or to prevent complicatoins Vasopressors to maintain perfusio Immobility: Histamine H2 blockers to prevent stress ulcers. anticoags to prevent DVT Stool softeners Antispasmodics for muscle spasms ```
28
SCI Collaborative Care: external stabilization/immobilization
Initially bed rest, log rolling, hard collar Align and stabilize the spine, decrease damaging motion, prevention of secondary injury, Traction (gardner-wells tongs, Halo vest)
29
SCI Collaborative Care: Surgical decompression and stabilization
Decompression of spinal cord/nerves Cone/tissue is pushing against the cord Realignment and stabilization of bone: spinal fusion, wiring or rods to hold vertebrae together
30
Nursing managment of immobolity
Log roll as a single uit, provide assistnace to keep alignment care, traction, collars, plints, braces, assitive deices for ADLs Flaccid paralysis: high top tennis shoes or splints to prevent contractures, frequent ROM Spastic paralysis: prevent spasms by avoiding sudden movements or jarring of the bed, internal stimulus Treat spasms by decreasing causes
31
Nursing managment of CVC
Assess VS with MAP of 85mmHg to perfuse the cord DO prevent/treat orthostatic hypotension assess BP, abd binder, calf compressors, TED hose, symptomatic treatment Minimize vagal stimulation DVT prophylaxis
32
Nursing managment Respiratory
Assess resp status above C4, total loss of resp function, mech ventilation below C4, diaphragmatic breathing, phrenic nerve DO airway management, suctioning, protect airway, physio Complications: secretion management, atelectasis, hypoventilation
33
Nursing Management: GI
Assess hypomobility, paralytic ileus, constipation, distention stress ulcers, malnourishment, DO bowel care, bowel training and nutrition, swallow assess, high fiber and fluid intake
34
Nursing Management GU
Assess incontinence, retention, UTI DO regular and complete bladder drainage, indwelling catheter, intermittent catheterizations q3-4 hours Flaccid bladder: automatic emptying of bladder, urine fills bladder and dribbles out spastic bladder: reflex arc but no connection to brain, reflex fires at will
35
Nursing Management: Integumentary
Assess skin breakdown | do position shifts, nutritional status, prevent surgical site infection
36
Nursing Management: psychosocial
Assess patient and family, overwhelming sense of loss, working through grief DO working towards adjustment, maintaining hope, control over environment, decreased sympathy, firm kindness, continual support
37
MAP = 2/3 ________+ 1/3____________ | what is the normal range?
2/3 diastolic + 1/3 systolic | 65-100
38
Intracranial pressure is exerted from the combined total volume of what 3 things? What is the range?
Brain tissue, CSF, Blood | 0-15
39
CPP=______ - _______? What is the range?
Cerebral Perfusion Pressure = MAP - ICP | 70-100
40
Scalp Laceration: Assessment and treatment
Assessment: mechanism of injury, if it gaps you would consider stitches, small unmoving lacerations can use skin glue Treatment: very vascular, visualize, closure, Rx: tetanus, antibiotic ungt
41
What are Skull fractures: Closed or Open?
A disruption/ break in the structure of the bone Force> bone strength Closed: skin intact Open: scalp laceration
42
Skull fracture: Linear skull fracture. What is it and what are the types??
``` Linear means aligned. Fracture line in cranial bone, but the bone does not move. Most common type of skull fracture. Types: Hairline, vault of the skull Basal, floor (base) of the skull Diastatic: along a suture line ```
43
Basal Skull Fracture Symptoms
Blood leaks from the fracture site: Racoon eyes d/t pooling (bilateral periorbital ecchymosis Battle's Sign, postauricular ecchymosis. Bruising behind the ear CSF Leakage from Meningeal Tear Otorrhea and rhinorrhea
44
Linear Skull Fracture: types according to # of fragments
Simple: Occurs along 1 line splitting the bone in 2 pieces Committed >2 fragments
45
Depressed Skull Fracture
Bone fragments are comminuted Fragments are displaced inward increases ICP by decreased volume of the skull
46
Brain Injury Severity: Mild
Initial GCS:13-15 | Degree of Post Traumatic Amnesia:
47
Brain Injury Severity: Moderate
Initial GCS: 9-12 Degree of Post Traumatic Amnesia: 1 to 7 days Duration of Loss of consciousness: >30 minutes to
48
Brain Injury Severity: Severe
Initial GCS: 3-8 Degree of Post Traumatic Amnesia: >7 days Duration of Loss of consciousness: >24 hours
49
What is the difference between retrograde amnesia and post-traumatic amnesia
Retrograde- memories shortly before the injury | Post-traumatic: confusion immediately following TBI, problems creating new memories
50
TBI: concussion
Traumatically induced alteration in mental status, with out without a loss of consciousness Memory loss, alteration of mental state, or personality, focal neurological deficits Balance/motor problems, disorientation, LOC, loss of memory, blank look, vomiting
51
What is post concussion syndrome?
One concussion puts you at risk for future events Symptoms of concussion can last > 3 months after the injury, wide range of symptoms: physical, such as headache, cognitive, difficulty concentrating, emotional and behavioural irritability.
52
What is chronic traumatic encephalopathy?
Memory loss, confusion, impaired judgment, reduced impulse control, aggression, explosive anger, depression, and progressive dementia
53
What is a TBI primary injury?
Impact injury | Damage is done, fractures, skull fractures, lacerations
54
What is a TBI Secondary injury?
Processes initiated by the trauma Occurs hours-days following injury 40% of TBI patients deteriorate Eg. Ischemia, cerebral edema
55
What is a TBI: Coup-Countrecoup injury?
Force of the initial blow s great enough to cause: Brain damage at the site of the initial impact between the skull and the brain Brain to move in the opposite direction and hit the opposite side of the skull, causing damage to the other side The side that received the initial blow it the coup The opposite of the initial impact is the countrecoup
56
Epidural Hematoma presentation and treatment
Caused by a focused blow to the head. Blood is pumped to the trauma and occupies the space. Must be caught and dealt with quickly. Presents: 85-95% of patients have an overlying fracture of the skull Majority located in the temporoparietal region where skull fractures cross the path of the middle meningeal artery Class presentation of brief LOC--lucid and decreased LOC Tx:surgical evacuation
57
Subdural hematoma presentation and treatment
Injury is below the dura, typically venous (slower) Most common type of traumatic intracranial lesion deceleration injury fall/MVA without skull fracture Presentation: Acute: within 48 hours of injury Sub-Acute: 2-14 days Chronic: Weeks to months Treatment: site and size dependant, surgical evacuation performed if necessary
58
Subarachnoid Hemorrhage
Between arachnoid and pia mater Usually a burst aneurism Occurs in 25-40% of patients with a moderate.severe head injury Up to 50% die or are left with impaired brain function
59
INtraparenchymal (Bleeding within the brain): | Intracerebral hemorrhage and intraventricular hemorrhage
intracerebral: Parenchymal injuries from lacerations of contusions, large deep vessel injury, pushes/compresses adjacent brain tissue Intraventricular: very severe TBI with a poor prognosis, very serious as the ventricles are ischemic
60
What is a Diffuse Axonal Injury?
Shear, twisting, forces causing wide spread axonal damage Can be mild to severe Outcome is unpredictable 90% remain in a vegetative state
61
What are signs and symptoms of neurological deterioration?
``` Any change in neuro status new onset seizure activity CSF leakage Pupillary changes vital signs- rising body temp, increased systolic pressure, bradycardia, chance in resp pattern posturing- decorticate or decerebrate ```
62
Eyes change on same side as injury and limbs change on opposite. T or F?
true
63
Early ICP, LOC, sensory, motor and other
Altered of decreased LOC, personality changes, confusion, restlessness, irritable Visual disturbances, subtle changes in speech decreased voluntary movement, contralateral hemiplegia (opposite side weakness), pronator drift (close eyes, hold limbs out and they will drop)
64
Late ICP, LOC, sensory, motor and other
Further decreased LOC, reduced responsiveness, impaired speech to aphasia, flexion -extension posturing, decreased or absent reflexes, pupillary changes, decreased reactivity, projectile vomiting with no nausea, cushing's triad
65
What is Cushing's Triad?
Cushing's triad is a clinical triad variably defined as having: Irregular respirations (caused by impaired brainstem function) Bradycardia. Systolic hypertension (Widening Pulse Pressure)
66
Cranial surgery: What is a Burr hole?
Opening into the cranium made with a drill, used to remove localized blood and fluid beneath the dura
67
Cranial surgery: What is a craniotomy?
Opening into the cranium with the removal of a bone flap, and opening the dura to remove a lesion, repair a damaged area, drain blood, or release increased ICP
68
Cranial surgery: What is a Craniectomy?
Excision into the cranium to cut away a bone flap.
69
Cranial surgery: What is a Cranioplasty?
Repair of a cranial defect resulting from trauma, malformation or previous surgical procedure, artificial material used to replace damaged or lost bone.
70
Nursing Management of patient's with a TBI, Assessments and Goals?
Airway, neuro assessment, vital signs and parameters, temp, cushings, MAP Complications: diabetes insipidus, SIADH, Seizure Goal: Normal Parameters ICP, SBP-MAP, Oxygenation, temperature, fluid balance,
71
Monitoring for complications: ADH
Peeing less, ADH is antidiuretic hormone released by the pituitary, promotes water absorption -DIabetes Insipidus: decreased ADH, Which equal excessive urine production TX: Synthetic ADH, fluid replacment Syndrome of Inappropriate ADH increased ADH high ADH equals low urine productions TX: fluid restriction
72
Nursing Management of Severe TBI: Maintain ICP at
Draining CSF decreases ICP Administering sedation prevents ICP increases Administering Mannitol is effective to decrease ICP THe diuretic effect of mannitol can cause increased sodium and serum osmolarity levels and should be monitored at regular intervals Elevate the head of the bed to 30 degrees and position patient in a neutral position Removing or loosening rigid collars may decrease ICP
73
Nursing Management of Severe TBI: Maintaining CPP between 50-70 mm Hg, optimizes cerebral perfusion
``` Continuous ICP monitoring Administering catecholamine (norepinephrine). ```
74
Nursing Management of Severe TBI: Preventing DVT
Pharmacological treatment may be safe for DVT prophylaxis | Applying mechanical prophylaxis on admission may assist to prevent DVT eg. Tinz BID
75
Nursing Management of Severe TBI: Adequate Nutrition
Initiating adequate nutrition within 72 hours of injury | Providing continuous intragastric feeding may improve tolerance
76
Nursing Management of Severe TBI:Glycemic Control
Insulin therapy, given IV drip, for elevated serum glucose can improve outcomes subcutaneous insulin admin has been shown to be unsafe and less effective than IV admin in critically ill patients
77
Nursing Management of Severe TBI: Seizures
Administering antiepileptic drugs
78
Brain Death- what is it define as?
Neurological determination of death, irreversible condition, no cortical or brainstem activity Absent brainstem reflexes: corneal response, oculocephalic reflex, oculovestibular reflex Absent Respiratory effort: apnea test

CNUR 305 (7 decks)

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